BOSTON – Children treated in the emergency department for abuse or neglect are at increased risk for further maltreatment, even after medical or social service intervention, a study has shown.
Among nearly 44,000 pediatric emergency department (ED) visits with at least one ICD-9 code for maltreatment, 3% of the children returned one or more times and were again identified as victims of maltreatment, reported Michael C. Monuteaux, Sc.D., of Harvard Medical School, Boston.
Dr. Michael C. Monuteaux
Children who were admitted to a patient floor or to an intensive care unit on their initial visit were twice as likely as those who were treated and released to be readmitted on subsequent ED visits. Children under 5 years of age were the most vulnerable, the authors found.
"Even when maltreatment is identified in the ED, children are at risk for further victimization resulting in future ED care," Dr. Monuteaux said at the annual meeting of the Pediatric Academic Societies.
Coinvestigator Dr. Daniel M. Lindberg, an emergency physician at Brigham and Women’s Hospital in Boston, said in an interview that the Child Protective Services workers have "a tremendously difficult" job made even more difficult by increasing caseloads and proposed reductions in funding.
"If that happens, [there will be] fewer investigators or case workers who can do the kind of checking in to make sure that safety plans are being followed or dangerous people are kept away from kids at risk. My hope is that any intervention to support Child Protective Services workers, and decrease caseloads, will help decrease rates of recurrent abuse," he said.
Dr. Monuteaux and Dr. Lindberg took a retrospective look at data from an administrative database on children under 18 treated in the emergency departments of 41 U.S. hospitals in 2005-2010.
They identified 43,824 ED visits by 42,354 children with one or more ICD-9 principal or secondary diagnoses of physical or sexual abuse, or other/unspecified maltreatment, and used medical record numbers to track patients over time.
In all, 1,286 maltreated children (3.0%) returned for another ED visit and received a second diagnosis of maltreatment. The median age of the children was 3 years (range, 1-8 years), 63% were girls, and 60% were white. The majority of the children (90%) had two ED visits, 8% had three visits, and 2% were seen in the ED four or more times.
One-fourth of the returning patients were seen again in the emergency department within 21 days, half within 150 days, and two-thirds within 1 year.
Abuse and neglect was the primary diagnosis in 38%, sexual abuse in 18%, physical abuse in 17%, and other maltreatment or injury in 27%.
Overall, 20% were admitted to the hospital at the initial visit, 3% were admitted to an ICU, and 6% underwent surgery for their injuries.
Of 253 children admitted at the initial visit, 42% were also admitted on their second visit. In comparison, of the 1,033 children not admitted at their first ED visit, 7% were admitted on the second visit. The odds ratio (OR) for being admitted a second time after a first admission was 2.1 (95% confidence interval [CI], 1.6-2.8).
Similarly, of 78 children with an initial ICU stay, 17% went back to the ICU at the second ED visit, compared with 2% of those who were not put in intensive care at their first ED visit (OR, 2.2; 95% CI, 1.4-3.6).
In a multivariate analysis controlled for demographic and clinical factors, the only significant predictor of repeat ED visits was age younger than 5 years (OR, 1.47; 95% CI, 1.22-1.78).
Dr. Monuteaux noted that the study might underestimate the actual number of repeat abuse cases because of its reliance on ICD-9 codes and because some of the children may have had ED visits for abuse or neglect before the start of the study. It is also possible that the code for physical abuse reflects long-term complications from prior abuse and not a new episode. Additionally, the data were drawn from academic pediatric hospitals and may not reflect the experience of community and general hospitals.
"Despite the dedicated work of ED and child protection workers, children diagnosed with maltreatment in the ED are at risk for additional victimization and subsequent emergency care for maltreatment, which leads us to suggest that improvements in the child protection apparatus should be considered," Dr. Monuteaux concluded.
The study was internally funded. The authors reported having no relevant financial relationships.